National Senior Citizen Mediclaim Policy

National Insurance Company Limited
CIN - U10200WB1906GOI001713 IRDAI Regn. No. - 58
National Senior Citizen Mediclaim Policy

PROSPECTUS
1.1 PRODUCT
National Senior Citizen Mediclaim Policy is an indemnity health insurance policy for the aged. The Policy covers expenses in
respect of inpatient treatment (allopathy, ayurveda and homeopathy), domiciliary hospitalisation, reasonably and customarily
incurred for treatment of a disease or an injury contracted/sustained during the policy period. The Policy also covers pre
hospitalisation and post hospitalisation expenses, 140+ day care procedures/surgeries, organ donor’s medical expenses, hospital
cash, ambulance charges, doctor’s home visit, nursing, aya and attendant charges during post hospitalization, funeral expenses,
reinstatement of SI due to Road Traffic Accident and regular medical consultation charges depending on the Plan opted.
Pre-existing Diabetes and/or Hypertension, Outpatient Treatment, Critical Illness and Personal Accident are provided as Optional
Covers.
1.2 COVERAGE
1.2.1 In-patient Treatment
The Company shall pay to the hospital or reimburse the insured, the medical expenses for:
i. Room charges and intensive care unit charges (including diet charges, nursing care by qualified nurse, RMO charges,
administration charges for IV fluids/blood transfusion/injection)
ii. Medical practitioner(s)
iii. Anaesthesia, blood, oxygen, operation theatre charges, surgical appliances
iv. Medicines and drugs
v. Diagnostic procedures
vi. Prosthetics and other devices or equipment if implanted internally during a surgical procedure.
vii. Dental treatment, necessitated due to an injury
viii. Plastic surgery, necessitated due to illness or injury
ix. Hormone replacement therapy, if medically necessary
x. Vitamins and tonics, forming part of treatment for illness/injury as certified by the attending medical practitioner
xi. Circumcision, necessitated for treatment of an illness or injury
1.2.1.1 Limit for Room Charges and Intensive Care Unit Charges
Room charges and intensive care unit charges per day shall be payable up to the limit as shown in the Table of Benefits. The limit
shall not apply if the treatment is undergone as a package for a listed procedure in a Preferred Provider Network (PPN).
1.2.1.2 Limit for Cataract Surgery and Benign Prostatic Hyperplasia

The Company’s liability for cataract surgery and Benign Prostatic Hyperplasia shall be up to the limit as shown in the Table of
Benefits, under Plan A only.
1.2.1.3 Treatment related to participation as a non-professional in hazardous or adventure sports

Expenses related to treatment necessitated due to participation as a non-professional in hazardous or adventure sports, subject
to Maximum amount admissible for Any One Illness shall be lower of 25% of Sum Insured.
1.2.2 Pre Hospitalisation

The Company shall reimburse the insured in respect of the medical expenses incurred 30 (thirty) days immediately before the
insured person is hospitalised, provided that:
i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the Company
Pre hospitalisation shall be considered as part of hospitalisation claim.
1.2.3 Post Hospitalisation

The Company shall reimburse the insured in respect of the medical expenses incurred 60 (sixty) days immediately after the
insured person is discharged from hospital, provided that:
i. such medical expenses are incurred for the same condition for which the insured person’s hospitalisation was required, and
ii. the in-patient hospitalisation claim for such hospitalisation is admissible by the Company
Post hospitalisation shall be considered as part of hospitalisation claim.
1.2.4 Domiciliary Hosptalisation

The Company shall reimburse the insured the medical expenses incurred under domiciliary hospitalisation, including pre
hospitalisation expenses and post hospitalisation expenses, up to the limit as shown in the Table of Benefits. Treating Medical
Practitioner shall have to certify the commencement date of Domiciliary Hospitalisation, and the necessity following the
circumstances mentioned below.
i. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii. the patient takes treatment at home on account of non-availability of room in a hospital.
Domiciliary Hospitalisation beyond the first 7 days shall be treated as Post Hospitalisation and shall be covered for the period
mentioned in Section 1.2.3 (Post Hospitalisation).
National Insurance Co. Ltd. Page | 1 National Senior Citizen Mediclaim Policy
Regd. & Head Office: 3, Middleton Street, (UIN: NICHLIP21083V022021)
Kolkata 700071
If the insured person is shifted to a Hospital as In-patient during the Domiciliary Hospitalisation for the same illness/ injury, the
Post Hospitalisation period shall start from the date of discharge.
Exclusions
Domiciliary hospitalisation shall not cover:
i. Treatment of less than three days
ii. Expenses incurred prior to or after Domiciliary hospitalization, for the same treatment
iii. Expenses incurred for AYUSH treatment
iv. Expenses incurred for any of the following diseases;
a) Asthma
b) Bronchitis
c) Chronic nephritis and nephritic syndrome
d) Diarrhoea and all type of dysenteries including gastroenteritis
e) Epilepsy
f) Influenza, cough and cold
g) All mental illnesses, psychiatric or psychosomatic disorders
h) Pyrexia of unknown origin for less than ten days
i) Tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis
j) Arthritis, gout and rheumatism
k) HIV/ AIDS
1.2.5 Daycare Procedure

The Company shall pay to the hospital/ day care centre or reimburse the insured the medical expenses and pre and post
hospitalisation expenses, for day care treatment of procedures/surgeries, provided that day care treatment is undergone by the
insured person in a hospital/ day care centre, but not the outpatient department of a hospital
In case of any other surgeries/procedures which would have otherwise required a hospitalization of more than 24 hours, but due to
advancement of medical science require hospitalisation for less than 24 hours, shall be covered subject to prior approval of the
Company/TPA.
1.2.6 Ayurveda and Homeopathy

The Company shall pay to the hospital or reimburse the insured the medical expenses for in-patient care, pre hospitalisation
expenses and post hospitalisation expenses, incurred for Ayurveda and Homeopathy treatment, provided the treatment is
undergone in an AYUSH Hospital.
1.2.7 HIV/ AIDS Cover

The Company shall pay to the hospital or reimburse the insured, the medical expenses for in-patient care, pre hospitalisation
expenses and post hospitalisation expenses, related to following stages of HIV infection:
1. Acute HIV infection – acute flu-like symptoms
2. Clinical latency – usually asymptomatic or mild symptoms
3. AIDS – full-blown disease; CD4 < 200
Exclusions
1. Any treatment undertaken as Out Patient shall not be covered.
2. Any treatment undertaken as Domiciliary hospitalization shall not be covered.
1.2.8 Mental Illness Cover

The Company shall pay to the hospital or reimburse the insured, the medical expenses for in-patient care, pre hospitalisation
expenses and post hospitalisation expenses, related to following mental illnesses:
1. Major Depressive Disorder- when the patient is aggressive or violent.
2. Acute psychotic conditions- aggressive/violent behaviour or hallucinations, incoherent talking or agitation.
3. Schizophrenia- esp. Psychotic episodes.
4. Bipolar disorder- manic phase.
The above covers are subject to the patient simultaneously exhibiting two or more of the following traits and requiring
hospitalisation as per the treating psychiatrist’s advice
• Suicidality
• Aggression
• Violent behaviour which are harmful to the patient and people around him
• Patients not responding to OPD drugs/treatments/therapy.
Condition
Treatment shall be undertaken at a Hospital categorized as Mental Health Establishment, under a Medical Practitioner qualified as
Mental Health Professional.
Exclusions
1. Any treatment undertaken as Out Patient shall not be covered.
2. Any treatment undertaken as Domiciliary hospitalization shall not be covered.
3. Any kind of Psychological counselling, cognitive/ family/ group/ behavior/ palliative therapy or other kinds of psychotherapy
for which hospitalisation is not necessary shall not be covered.
Kolkata 700071
1.2.9 Organ Donor’s Medical Expenses
The Company shall pay to the hospital or reimburse the insured the medical expenses for in-patient care, pre hospitalisation
expenses and post hospitalisation expenses of the organ donor, during the course of organ transplant to the insured person,
provided
i. the donation conforms to ‘The Transplantation of Human Organs Act 1994’ and the organ is for the use of the insured person
ii. the insured person has been medically advised to undergo an organ transplant,
Exclusions
The Company shall not be liable to make any payment in respect of any expenses incurred in connection with or in respect of
1. Cost of the organ to be transplanted.
2. Any other medical treatment or complication in respect of the donor, consequent to harvesting.
1.2.10 Ambulance Charges

The Company shall reimburse the insured the expenses incurred for actual emergency ambulance charges for transportation to the
hospital or from the hospital to another hospital or from the hospital to diagnostic center and return during the same
hospitalization period, provided a claim has been admitted as Section In-patient Treatment. Ambulance charges will be subject to
maximum INR 2,500 for Any One Illness for each insured person.
1.2.11 Modern Treatment

The Company shall pay to the hospital or reimburse the insured the medical expenses for In-Patient Care, Domiciliary
Hosptalisation or Day Care Procedure along with pre hospitalisation expenses and post hospitalisation expenses incurred for
following Modern Treatments (wherever medically indicated), subject to Maximum amount admissible for any one Modern
Treatment shall be 25% of Sum Insured
A. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
B. Balloon Sinuplasty
C. Deep Brain stimulation
D. Oral chemotherapy
E. Immunotherapy- Monoclonal Antibody to be given as injection
F. Intra vitreal injections
G. Robotic surgeries
H. Stereotactic radio surgeries
I. Bronchical Thermoplasty
J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
K. IONM - (Intra Operative Neuro Monitoring)
L. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
1.2.12 Morbid Obesity Treatment

The Company shall indemnify the Hospital or the Insured the Medical Expenses, including pre hospitalisation expenses and post
hospitalisation expenses, incurred for surgical treatment of obesity that fulfils all the following conditions and subject to Waiting
Period of four (04) years as per Section 4.2.f.iv:
1. Treatment has been conducted is upon the advice of the Medical Practitioner, and
2. The surgery/Procedure conducted should be supported by clinical protocols, and
3. The Insured Person is 18 years of age or older, and
4. Body Mass Index (BMI) is;
b) greater than or equal to 40 or
c) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive
methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type 2 Diabetes
1.2.13 Correction of Refractive Error

The Company shall indemnify the Hospital or the Insured the Medical Expenses, including pre hospitalisation expenses and post
hospitalisation expenses, incurred for expenses related to the treatment for correction of eye sight due to refractive error equal to
or more than 7.5 dioptres, subject to Waiting Period of two (02) years as per Section 4.2.f.iii.
Note: The expenses that are not covered in this policy are placed under List-l of Appendix-II of the Policy. The list of expenses
that are to be subsumed into room charges, or procedure charges or costs of treatment are placed under List-II, List-III and List-IV
of Appendix-II of the Policy respectively
1.3 ADDITIONAL BENEFITS AVAILABLE IN PLAN B

1.3.1 Hospital Cash
The Company shall pay the insured a daily hospital cash allowance up to the limit as shown in the Table of Benefits for a
maximum of five (05) days, provided
i. The hospitalisation exceeds three (03)days.
ii. A claim has been admitted as per Section In-patient Treatment.
Kolkata 700071
Hospital Cash shall be payable for each day from the 4th day of Hospitalisation up to the 8th day of Hospitalisation only.
Illustration
In case of hospitalisation of 3 days – No Hospital Cash payable
In case of hospitalisation of 5 days – Hospital Cash payable for 4th and 5th day only, i.e., 2 days
In case of hospitalisation of 10 days – Hospital Cash payable for 4th to 8th day, i.e., 5 days
1.3.2 Doctor’s Home Visit/ Aya/ Nurse/ attendant Charges during Post Hospitalisation
The Company shall reimburse the insured, for medically necessary expenses incurred for doctor’s home visit, nursing care by
qualified nurse, aya, attendant charges during post hospitalisation up to the limit as shown in the Table of Benefits, provided the
related hospitalisation claim has been admitted as per Section In-patient Treatment and the physical mobility of the insured person
outside residence is severely restricted as advised in the discharge summary.
1.3.3Funeral Expenses
In the event of death of the insured person during hospitalisation, the Company shall pay funeral expenses subject to limit as
mentioned in Table of Benefit provided hospitalisation claim is admitted as per Section In-patient Treatment.
1.3.4Reinstatement of Sum Insured if exhausted due to Road Traffic Accident

In the event of available sum insured in respect of the insured/ insured person being exhausted anytime during the policy period
on account of hospitalisation/ domiciliary hospitalisation claims arising out of any injury due to a road traffic accident (RTA), the
Company shall reinstate the sum insured (excluding Cumulative Bonus) to the extent as available prior to such RTA
hospitalization, for any subsequent hospitalization(s) expenses that the insured/ insured person may incur due to any other disease/
injury during the balance policy period.
i. In a policy issued on individual basis, reinstatement of sum insured shall be available in respect of the insured person whose
sum insured is exhausted as specified above. In a policy issued on floater basis, reinstatement shall be available to floater sum
insured subject to exhaustion of sum insured as specified above by either or both of the insured persons.
ii. Reinstated sum insured shall be the amount of balance sum insured prior to the RTA, which is exhausted due to the RTA
hospitalisation/ domiciliary hospitalisation claim.
iii. Reinstatement shall be allowed only once during the policy period
iv. Reinstated sum insured shall not be available for the Hospitalisation claim due to which the sum insured has exhausted, but
shall be available only for subsequent hospitalization(s) due to any other disease/ injury (Subject to Definition ‘Any One
Illness’).
v. Maximum liability of the Company under a single claim and any one illness shall not exceed the sum insured.
vi. Reinstated sum insured, if not exhausted, will not be carried forward to next policy period on renewal.
Illustration:
Case I: SI – INR 5L Case II: SI – INR 5L
Claim 1 (hospitalization due to disease) – INR 2L Claim 1 (hospitalization due to RTA) – INR 4L
Balance SI – INR 5L, Amount admissible – INR 2L Balance SI – INR 5L, Amount admissible – INR 4L
SI exhausted – No, SI remaining – INR 3L SI exhausted – No, SI remaining – INR 1L
SI reinstated – No SI reinstated – No
Claim 2 (hospitalization due to RTA) – INR 4L Claim 2 (hospitalization due to disease) – INR 2L
Balance SI – INR 3L, Amount admissible – INR 3L Balance SI – INR 1L, Amount admissible – INR 1L
SI exhausted – Yes, SI remaining – INR 0 SI exhausted – Yes, SI remaining – INR 0
SI reinstated – Yes [INR 3L, i.e., balance SI prior to RTA] SI reinstated – No
(though SI is reinstated, it will be available in next claim) (SI is not reinstated as not exhausted due to RTA)
Claim 3 (hospitalization due to disease) – INR 1L Claim 3 (hospitalization due to disease/ RTA) – INR 1L
Balance Reinstated SI – 3L Amount admissible – INR 1L Amount admissible – INR 0
SI remaining – INR 2L (no amount available)
1.4 GOOD HEALTH INCENTIVE

1.4.1 Cumulative Bonus (CB)
For policies issued on individual basis
At the time of renewal, cumulative bonus allowed shall be an amount equal to 5% (five percent) of sum insured (excluding CB) of
the expiring policy in respect of the insured person provided no claim has been reported under the expiring policy.
In the event of a claim being reported under the expiring policy the cumulative bonus with respect to the insured person shall be
reduced by an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy. However, the reduction of
CB will not impact sum insured (excluding CB).
Cumulative bonus shall be accrued over the years, subject to maximum of 50% (fifty percent) of the sum insured (excluding CB)
of the current policy.
For policies issued on floater basis

At the time of renewal, cumulative bonus allowed shall be an amount equal to 5% (five percent) of the floater sum insured
(excluding CB) of the expiring policy provided no claim has been reported under the expiring policy by any insured person.
Kolkata 700071
In the event of a claim being reported under the expiring policy the cumulative bonus with respect to the insured family shall be
reduced by an amount equal to 5% (five percent) of sum insured (excluding CB) of the expiring policy. However, the reduction of
CB will not impact sum insured (excluding CB).
Cumulative bonus shall be accrued over the years, subject to maximum of 50% (fifty percent) of the sum insured (excluding CB)
of the current policy.
1.4.2 Preventive Health Check Up

1.4.2.1 Applicable to Plan A
Expenses of prescribed diagnostic tests only with respect to the insured person(s), shall be reimbursed at the end of a block of two
continuous policy periods, provided claims are not reported during the block in respect of the insured person(s) and the Policy has
been continuously renewed with the Company without a break. Expenses payable are subject to the limit as shown in the Table of
Benefits.
1.4.2.2 Applicable to Plan B

Expenses of medical consultation incurred as Out Patient and prescribed diagnostic tests only (excluding cost of prescribed
medicines) with respect to the insured person(s), up to the limit as mentioned in the Table of Benefit during a block of six months,
shall be reimbursed provided no claims are reported during the block in respect of the insured person(s). Claim for both blocks
shall be submitted once, after the end of the policy.
For the purpose of this section, the block of first 6 months shall commence from the inception of the policy till end of 6 months
from inception and block of second 6 months shall commence from 7 th month of the policy period till expiry of the policy period.
Note: Claims under Section Preventive Health Check Up shall not count as claims under the Policy, for the purpose of
determining eligibility for subsequent claims under Section Preventive Health Check Up.
1.5 Hospitalisation Options

The Policy provides for cashless facility and/ or reimbursement of hospitalisation or domiciliary hospitalisation expenses for
treatment of disease or injury.
Cashless facility is available only in network providers, if opted for TPA service, subject to prior approval by the TPA.
2.1 Type of Policy

Policy can be issued, as opted by the Proposer, on
i. Individual Basis (i.e., separate Sum Insured shall apply on each insured person)
ii. Floater Basis (same Sum Insured shall apply to cover both insured person)
2.2 Proposer
Policy can be proposed by,
i. Any Senior Citizen (i.e., aged between 60 to 80 years).
ii. Son or Daughter for parents, where at least one parent is Senior Citizen (i.e., aged between 60 to 80 years)
No one else can be Proposer for this Policy.
2.3Eligibility
i. If Proposer is the Senior Citizen, Policy on Individual Basis can be availed for
a. Self only aged between 60 to 80 years at inception.
b. Self and Spouse, both aged between 60 to 80 years at inception.
ii. If Proposer is the Senior Citizen, Policy on Floater Basis can be availed for
a. Self and Spouse together, where self is aged between 60 to 80 years and spouse is aged between 50 to 80 years
at inception.
iii. If Son or Daughter is the Proposer, Policy on Individual Basis can be availed for
a. Either Father or Mother, aged between 60 to 80 years at inception
b. Father and Mother, both aged between 60 to 80 years at inception
iv. If Son or Daughter is the Proposer, Policy on Floater Basis can be availed for
a. Father and Mother together, where at least one parent is aged between 60 to 80 years and the other aged between
50 to 80 years at inception.
No other relation even within the eligible age band can be covered under the Policy.
2.4 Policy Period

The Policy can be issued for a period of one (01) year.
2.5 Plans
The Policy is available under two Plans, with varying covers.
i. Plan A
ii. Plan B
2.6 Sum Insured (SI)

i. The Policy is available with following SI under both Individual Basis and Floater Basis.
Plan A – 10 slabs, INR 1,00,000 to INR 10,00,000 in multiple of INR 1,00,000
Plan B – 10 slabs, INR 1,00,000 to INR 10,00,000 in multiple of INR 1,00,000
Kolkata 700071
2.6.1 Enhancement of Sum Insured
i. Sum insured can be enhanced only at the time of renewal, to the next higher slab.
ii. For the incremental portion of the SI, the waiting periods and conditions as mentioned in Exclusion 4.1, 4.2, 4.3 shall apply.
Coverage on enhanced sum insured shall be available after the completion of waiting periods.
iii. Proposal for change of plan is allowed after four years of continuous coverage and only at the time of renewal, subject to
discretion of the Company.
2.7 Discounts
2.7.1 Discount for Direct Sale
For Policy bought by walk in customer (where no intermediary is involved) - Discount of 10% shall be allowed on the final
payable premium for new and subsequent renewals.
2.8Tax Rebate
The Proposer can avail tax benefits for the premium paid, under Section 80D of Income Tax Act 1961.
2.9 Completion of Proposal Form

i. The proposal form is to be completed in all respects (including personal details, medical history of insured person) and to be
submitted to the office or to the intermediary.
ii. Identity and address of the proposer must be supported by documentary proofs, as detailed in Proposal Form Annexure C.
iii. If a person is insured under health insurance policy of any other Non-Life Insurance Company and wants to port (switch) to
National Senior Citizen Mediclaim Policy, the Portability Form and Proposal Form will have to be completed and
submitted to the office or to the intermediary.
2.10 Pre Policy Checkup

i. Pre Policy Checkup is required for all individual irrespective of age, for fresh proposal.
ii. The Company shall reimburse 50% of the expenses incurred for Pre Policy Checkup, if the proposal is accepted and the
premium has been realised.
iii. The Pre Policy Checkup reports required are –
a) Physical examination (report to be signed by the Doctor with minimum MD (Medicine) qualification)
b) HbA1c
c) Lipid profile
d) Serum creatinine
e) Urine routine and microscopic examination
f) ECG
g) Eye checkup (including retinoscopy)
h) Any other investigation required by the Company
Note:
The date of medical reports should not exceed thirty (30) days prior to the date of proposal.
2.11 Payment of Premium

i. In case of Individual Policy, premium for each individual shall depend on the Plan, SI and age from the ‘Premium Table for
Individuals’.
ii. In case of Floater Policy, premium for senior most member shall depend on the Plan, SI and age from the ‘Premium Table for
Senior Most Member’ and premium for spouse shall depend on age for same Plan and same SI from ‘Premium Table for
Spouse’.
iii. Base premium of the policy shall be total premium for both individual, calculated as mentioned above.
iv. Premium for Optional cover depends upon the cover(s) opted.
v. The proposer has the option of claims being serviced by TPA (in which case cashless facility/reimbursement of expenses will
be available) or the Company (in which case expenses will be reimbursed). If cashless facility is to be availed, the premium
payable is inclusive of TPA charges. If cashless facility is not required, the premium payable shall be discounted by 6%.
vi. Premium as per the premium table attached is to be paid in full before the commencement of the policy.
vii. Premium can be paid online for renewals without break, provided there is no material change in the policy.
viii. PAN details must be submitted by the insured.
ix. In case PAN is not available, Form 60 or Form 61 as per Rule 114B of the Income-tax Rule,1962 must be submitted
2.12 Renewal of Policy

i. The policy can be renewed without break throughout the lifetime of the insured person.
ii. The policy may be renewed by mutual consent before the expiry of the policy.
iii. The Company is not bound to send renewal notice.
iv. Renewal of policy can be denied on grounds of fraud, moral hazard, misrepresentation or noncooperation.
v. In the event of break in the policy a grace period of thirty days is allowed. Coverage is not available during the grace period.
vi. If during the policy period, the number of members covered in the policy issued on Floater Basis reduces to a single
member(due to death or any other valid and acceptable reason), then on renewal the Policy shall continue on Individual Basis
for the surviving member as insured, even if he/ she is aged between 50-60 yrs. In such cases the surviving insured person has
option to reduce the sum insured. Any CB earned shall also be reduced in same proportion as per the opted sum insured and
the expiring sum insured.
Kolkata 700071
3 DEFINITIONS
3.1 Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
3.2 AIDS means Acquired Immune Deficiency Syndrome, a condition characterised by a combination of signs and symptoms,
caused by Human Immunodeficiency Virus (HIV), which attacks and weakens the body’s immune system making the HIV-
positive person susceptible to life threatening conditions or other conditions, as may be specified from time to time.
3.3 Any One Illness means continuous period of illness and it includes relapse within forty five days from the date of last
consultation with the hospital where treatment has been taken.
3.4 AYUSH Treatment refers to the medical and / or hospitalization treatments given Ayurveda, Yoga and Naturopathy,
Unani, Sidha and Homeopathy systems.
3.5 AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions
are carried out by AYUSH Medical Practitioner(s) comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognized by the Central Government/ Central Council of Indian
Medicine/ Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH
Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required;
iv. Maintaining daily records of the patients and making them accessible to the insurance company’s authorized
representative
3.6 Break in Policy occurs at the end of the existing policy period when the premium due on a given Policy is not paid on or
before the renewal date or within grace period.
3.7 Cashless Facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment
undergone by the insured in accordance with the Policy terms and conditions, are directly made to the network provider by
the insurer to the extent pre-authorization approved.
3.8 Condition Precedent means a Policy term or condition upon which the Company’s liability under the Policy is conditional
upon.
3.9 Contract means prospectus, proposal, Policy, and the policy schedule. Any alteration with the mutual consent of the
insured person and the insurer can be made only by a duly signed and sealed endorsement on the Policy.
3.10 Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form,
structure or position.
a) Internal Congenital Anomaly
Congenital anomaly which is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital anomaly which is in the visible and accessible parts of the body.
3.11 Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured
will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.
3.12 Day Care Centre means any institution established for day care treatment of disease/ injuries or a medical setup within a
hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a
registered and qualified medical practitioner AND must comply with all minimum criteria as under:
i. has qualified nursing staff under its employment;
ii. has qualified medical practitioner (s) in charge;
iii. has a fully equipped operation theatre of its own where surgical procedures are carried out
iv. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
3.13 Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under general or local anesthesia in a hospital/day care centre in less than twenty four hrs because of technological
advancement, and
ii. which would have otherwise required a hospitalisation of more than twenty four hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
3.14 Dental Treatment means a treatment carried out by a dental practitioner including examinations, fillings (where
appropriate), crowns, extractions and surgery.
Kolkata 700071
3.15 Diagnosis means diagnosis by a medical practitioner, supported by clinical, radiological, histological and laboratory
evidence, acceptable to the Company.
3.16 Domiciliary Hospitalization means medical treatment for an illness/disease/injury which in the normal course would
require care and treatment at a hospital but is actually taken while confined at home under any of the following
circumstances:
i. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
ii. the patient takes treatment at home on account of non-availability of room in a hospital.
3.17 Floater Sum Insured means the sum insured mentioned in the Schedule, which is applicable to all the insured persons, for
any and all claims made in aggregate during the policy period.
3.18 Grace Period means thirty (30) days immediately following the premium due date during which a payment can be made to
renew or continue the Policy in force without loss of continuity benefits such as waiting period and coverage of pre-existing
diseases. Coverage is not available for the period for which no premium is received.
3.19 Hospital means any institution established for in-patient care and day care treatment of disease/ injuries and which has
been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act,
2010 or under the enactments specified under Schedule of Section 56(1) of the said Act, OR complies with all minimum
criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least ten inpatient beds, in those towns having a population of less than ten lacs and fifteen (15) inpatient beds in all
other places;
iii. has qualified medical practitioner (s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out
v. maintains daily records of patients and shall make these accessible to the Company’s authorized personnel.
3.20 Hospitalisation means admission in a hospital or mental health establishment for a minimum period of twenty four (24)
consecutive ‘Inpatient care’ hours except for specified procedures/ treatments, where such admission could be for a period
of less than twenty four (24) consecutive hours.
3.21 ID Card means the card issued to the insured person by the TPA for availing cashless facility in the network provider.
3.22 Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function
which manifests itself during the policy period and requires medical treatment.
i. Acute Condition means a disease, illness or injury that is likely to response quickly to treatment which aims to return the
person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
ii. Chronic Condition means a disease, illness, or injury that has one or more of the following characteristics
a) it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and / or tests
b) it needs ongoing or long-term control or relief of symptoms
c) it requires rehabilitation for the patient or for the patient to be special trained to cope with it
d) it continues indefinitely
e) it recurs or is likely to recur
3.23 In-Patient Care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered
event.
3.24 Insured/ Insured Person means person(s) named in the schedule of the Policy.
3.25 Intensive Care Unit means an identified section, ward or wing of a hospital which is under the constant supervision of a
dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients
who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably
more sophisticated and intensive than in the ordinary and other wards.
3.26 ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses on a per day basis
which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including
monitoring devices, critical care nursing and intensivist charges.
3.27 Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent
and visible and evident means which is verified and certified by a medical practitioner.
3.28 Medical Advice means any consultation or advice from a Medical Practitioner including the issue of any prescription or
follow up prescription.
3.29 Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment
on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been
payable if the insured person had not been insured and no more than other hospitals or doctors in the same locality would
have charged for the same medical treatment.
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3.30 Medically Necessary means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which
i. is required for the medical management of illness or injury suffered by the insured ;
ii. must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or
intensity;
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international medical practice or by the medical community in
India.
3.31 Medical Practitioner means a person who holds a valid registration from the Medical Council of any state or Medical
Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State
Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of the licence.
3.32 Mental Illness means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs
judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions
associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or
incomplete development of mind of a person, specially characterised by subnormality of intelligence.
Mental Illness covered under the Policy shall be as specified in Section Mental Illness. Neurological disorders
(Alzheimer’s, Parkinsonism, Myasthenia Gravis, etc.), learning disabilities or mental retardation does not constitute Mental
Illness.
3.33 Mental Health Establishment shall mean any health establishment meeting the criteria of Hospital, as defined in
Definition 3.18, and includes Ayurveda and Homoeopathy establishment, by whatever name called, meant for the care of
persons with mental illness.
3.34 Mental Health Professional means a medical practitioner, as defined in Definition 3.31 and practicing as
(i) a Psychiatrist, as defined in Definition 3.44; or
(ii) a professional having a post-graduate degree (Ayurveda) in Mano Vigyan Avum Manas Roga or a post-graduate degree
(Homoeopathy) in Psychiatry.
3.35 Network Provider means hospitals enlisted by insurer, TPA or jointly by an insurer and TPA to provide medical services
to an insured by a cashless facility. In cities with Preferred Provider Network (Definition 3.41), PPN are the only Network
Providers.
3.36 Non- Network means any hospital, day care centre or other provider that is not part of the network.
3.37 Notification of Claim means the process of intimating a claim to the Insurer or TPA through any of the recognized modes
of communication.
3.38 Out-Patient Treatment means treatment in which the insured visits a clinic / hospital or associated facility like a
consultation room for diagnosis and treatment based on the advice of a medical practitioner. The insured is not admitted as a
day care or in-patient.
3.39 Policy Period means period of one year as mentioned in the schedule for which the Policy is issued.
3.40 Pre Existing Disease means any condition, ailment, injury or disease
a. That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the
Company or its reinstatement or
b. For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior
to the effective date of the policy issued by the Company or its reinstatement.
3.41 Preferred provider network (PPN) means network providers in specific cities which have agreed to a cashless packaged
pricing for specified planned procedures for the policyholders of the Company. The list of planned procedures is available
with the Company/TPA and subject to amendment from time to time. Reimbursement of expenses incurred in PPN for the
procedures (as listed under PPN package) shall be subject to the rates applicable to PPN package pricing.
3.42 Pre-hospitalization Medical Expenses means medical expenses incurred during predefined number of days preceding the
hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
3.43 Post-hospitalization Medical Expenses: means medical expenses incurred during predefined number of days immediately
after the insured person is discharged from the hospital provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the Insurance Company.
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3.44 Psychiatrist means a medical practitioner possessing a post-graduate degree or diploma in psychiatry awarded by an
university recognised by the University Grants Commission established under the University Grants Commission Act,
1956, or awarded or recognised by the National Board of Examinations and included in the First Schedule to the Indian
Medical Council Act, 1956, or recognised by the Medical Council of India, constituted under the Indian Medical Council
Act, 1956, and includes, in relation to any State, any medical officer who having regard to his knowledge and experience in
psychiatry, has been declared by the Government of that State to be a Psychiatrist.
3.45 Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council
of any state in India.
3.46 Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the
specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking
into account the nature of the illness/ injury involved.
3.47 Room Rent means the amount charged by a hospital towards Room and Boarding expenses and shall include the associated
medical expenses.
3.48 Renewal means the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace
period for treating the renewal continuous for the purpose of gaining credit for pre-existing diseases, time-bound exclusions
and for all waiting periods.
3.49 Schedule means a document forming part of the Policy, containing details including name of the insured person, age,
relation of the insured person, sum insured, premium paid and the policy period.
3.50 Sum insured means the sum insured and the cumulative bonus (CB) accrued in respect of the insured person (s) as
mentioned in the schedule. Health checkup expenses are payable over and above the sum insured, wherever applicable.
3.51 Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or
injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering and prolongation of life,
performed in a hospital or day care centre by a medical practitioner.
3.52 Third Party Administrator (TPA) means a Company registered with the Authority, and engaged by an insurer, for a fee or
remuneration, by whatever name called and as may be mentioned in the agreement, for providing health services.
3.53 Unproven/ Experimental Treatment means treatment, including drug experimental therapy, which is not based on
established medical practice in India, is experimental or unproven.
3.54 Waiting Period means a period from the inception of this Policy during which specified diseases/treatments are not
covered. On completion of the period, diseases/treatments shall be covered provided the Policy has been continuously
renewed without any break.
4 WAITING PERIOD - EXCLUSIONS

The Company shall not be liable to make any payment under the policy till the expiry of waiting period mentioned below, in
respect of any expenses incurred in connection with or in respect of:
4.1. Pre-Existing Diseases (Excl 01)

a) Expenses related to the treatment of a Pre-Existing Disease (PED) and its direct complications shall be excluded until the
expiry of twenty four (24) months of continuous coverage after the date of inception of the first policy with us.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c) If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI
(Health Insurance) Regulations then waiting period for the same would be reduced to the extent of prior coverage.
d) Coverage under the policy after the expiry of twenty four (24) months for any pre-existing disease is subject to the same
being declared at the time of application and accepted by us.
4.2. Specified disease/procedure waiting period (Excl 02)

a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 90 days/
one year/ two year/ four years (as specified against specific disease/ procedure) of continuous coverage after the date of
inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
c) If any of the specified disease/procedure falls under the waiting period specified for Pre-Existing Diseases, then the longer
of the two waiting periods shall apply.
d) The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a
specific exclusion.
e) If the Insured Person is continuously covered without any break as defined under the applicable norms on portability
stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.
f) List of specific diseases/procedures
i. 90 Days Waiting Period (Life style conditions)
a. Hypertension and related complications
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b. Diabetes and related complications
c. Cardiac conditions
ii. One year waiting period
a. Benign ENT disorders d. Mastoidectomy
b. Tonsillectomy e. Tympanoplasty
c. Adenoidectomy
Above diseases/treatments under 4.2.ii shall be covered after the specified waiting period, provided they are not pre existing
disease.
iii. Two years waiting period
a. Cataract l. Calculus diseases
b. Benign prostatic hypertrophy m. Surgery of gall bladder and bile duct excluding
c. Hernia malignancy
d. Hydrocele n. Surgery of genito-urinary system excluding malignancy
e. Fissure/Fistula in anus o. Surgery for prolapsed intervertebral disc unless arising
f. Piles (Haemorrhoids) from accident
g. Sinusitis and related disorders p. Surgery of varicose vein
h. Polycystic ovarian disease q. Hysterectomy
i. Non-infective arthritis r. Refractive error of the eye more than 7.5 dioptres.
j. Pilonidal sinus s. Congenital Internal Anomaly
k. Gout and Rheumatism
iv. Four years waiting period
a. Joint replacement unless necessitated due to an accident
b. Osteoarthritis and osteoporosis
c. Morbid Obesity and its complications
d. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.
Above diseases/treatments under 4.2.iv, even if pre-existing shall be covered after waiting period four years, including the waiting
period for pre-existing disease.
4.3. First 30 days waiting period (Excl 03)

a) Expenses related to the treatment of any illness within thirty (30) days from the first policy commencement date shall be
excluded except claims arising due to an accident, provided the same are covered.
b) This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve (12) months.
c) The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum
insured subsequently.
5 PERMANENT EXCLUSIONS
The Company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or
in respect of:
5.1. Investigation& Evaluation (Excl 04)

a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
5.2. Rest Cure, Rehabilitation and Respite Care (Excl 05)

a) Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing,
dressing, moving around either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
5.3. Obesity/ Weight Control (Excl 06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a. greater than or equal to 40 or
b. greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive
methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
5.4. Change-of-Gender Treatments (Excl 07)

Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite
sex.
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5.5. Cosmetic or Plastic Surgery (Excl 08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident,
Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this
to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
5.6. Hazardous or Adventure Sports (Excl 09)

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including
but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding,
sky diving, deep-sea diving.
5.7. Breach of Law (Excl 10)

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach
of law with criminal intent.
5.8. Excluded Providers (Excl 11)

Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by
the Company and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening
situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
5.9. Drug/Alcohol Abuse (Excl 12)

Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Excl 12).
5.10. Non Medical Admissions (Excl 13)

Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing
home attached to such establishments or where admission is arranged wholly or partly for domestic reasons (Excl 13).
5.11. Vitamins, Tonics (Excl 14)

Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals
and organic substances unless prescribed by a medical practitioners part of hospitalization claim or day care procedure
5.12. Refractive Error (Excl 15)

Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.
5.13. Unproven Treatments (Excl16)

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments
are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
5.14. Birth control, Sterility and Infertility (Excl 17)

Expenses related to sterility and infertility. This includes:
i. Any type of sterilization
ii. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT,
GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization
5.15. Maternity (Excl 18)

i. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during
hospitalization) except ectopic pregnancy;
ii. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period
5.16. Hormone Replacement Therapy

Expenses for hormone replacement therapy, unless part of Medically Necessary Treatment, except for Puberty and Menopause
related Disorders.
5.17. General Debility, Congenital External Anomaly

General debility, Congenital external anomaly.
5.18. Self Inflicted Injury

Treatment for intentional self-inflicted injury, attempted suicide.
5.19. Stem Cell Surgery

Stem Cell Surgery (except Hematopoietic stem cells for bone marrow transplant for haematological conditions).
5.20. Circumcision
Circumcision unless necessary for treatment of a disease (if not excluded otherwise) or necessitated due to an accident.
Kolkata 700071
5.21. Vaccination or Inoculation.
Vaccination or inoculation unless forming part of treatment and requires Hospitalisation.
5.22. Massages, Steam Bath, Alternative Treatment (Other than Ayurveda and Homeopathy)
Massages, steam bath, expenses for alternative or AYUSH treatments (other than Ayurveda and Homeopathy), acupuncture,
acupressure, magneto-therapy and similar treatment.
5.23. Dental treatment

Dental treatment, unless necessitated due to an Injury.
5.24. Out Patient Department (OPD) treatment

Any expenses incurred on OPD treatment, except as and to the extent provided for under Section Preventive Health Check Up -
Applicable to Plan B.
5.25. Stay in Hospital which is not Medically Necessary.

Stay in hospital which is not medically necessary.
5.26. Spectacles, Contact Lens, Hearing Aid, Cochlear Implants

Spectacles, contact lens, hearing aid, cochlear implants.
5.27. Non Prescription Drug

Drugs not supported by a prescription, private nursing charges, referral fee to family physician, outstation
doctor/surgeon/consultants’ fees and similar expenses.
5.28. Treatment not Related to Disease for which Claim is Made

Treatment which the insured person was on before Hospitalisation for the Illness/Injury, different from the one for which claim for
Hospitalisation has been made.
5.29. Equipments
External/durable medical/non-medical equipments/instruments of any kind used for diagnosis/ treatment including CPAP, CAPD,
infusion pump, ambulatory devices such as walker, crutches, belts, collars, caps, splints, slings, braces, stockings, diabetic foot-
wear, glucometer, thermometer and similar related items and any medical equipment which could be used at home subsequently.
5.30. Items of personal comfort

Items of personal comfort and convenience including telephone, television, barber, beauty services, baby food, cosmetics,
napkins, toiletries, guest services.
5.31. Service charge/ registration fee

Any kind of service charges including surcharges, admission fees, registration charges and similar charges levied by the hospital.
5.32. Home visit charges

Home visit charges during Pre and Post Hospitalisation of doctor, aya, attendant and nurse, except as and to the extent provided
for under Section Doctor’s Home Visit/ Aya/ Nurse/ attendant Charges during Post Hospitalisation.
5.33. War
War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion,
revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
5.34. Radioactivity
Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from or from any other cause or event
contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:
a) Nuclear attack or weapons means the use of any nuclear weapon or device or waste or combustion of nuclear fuel or the
emission, discharge, dispersal, release or escape of fissile/ fusion material emitting a level of radioactivity capable of causing
any Illness, incapacitating disablement or death.
b) Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical
compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
c) Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing)
micro-organisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized
toxins) which are capable of causing any Illness, incapacitating disablement or death.
5.35. Treatment taken outside the geographical limits of India
5.36. Permanently Excluded Diseases

In respect of the existing diseases, disclosed by the insured and mentioned in the policy schedule (based on insured's
consent), policyholder is not entitled to get the coverage for specified ICD codes.
Kolkata 700071
6 CONDITIONS
6.1 Disclosure of Information

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis
description or non-disclosure of any material fact by the policyholder.
(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information sought by the company in the
proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk).
6.2 Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s)
arising under the policy.
6.3 Communication
i. All communication should be made in writing.
ii. For Policies serviced by TPA, ID card, PPN/network provider related issues to be communicated to the TPA at the address
mentioned in the schedule. For claim serviced by the Company, the Policy related issues to be communicated to the Policy
issuing office of the Company at the address mentioned in the schedule.
iii. Any change of address, state of health or any other change affecting any of the insured person, shall be communicated to the
Policy issuing office of the Company at the address mentioned in the schedule
iv. The Company or TPA shall communicate to the insured at the address mentioned in the schedule.
6.4 Physical Examination

Any medical practitioner authorised by the Company shall be allowed to examine the insured person in the event of any alleged
injury or disease requiring hospitalisation when and as often as the same may reasonably be required on behalf of the Company.
6.5 Claim Procedure

6.5.1 Notification of Claim
In order to lodge a claim under the Policy for any hospitalisation/ domiciliary hospitalisation, the insured person/insured person’s
representative shall notify the TPA (if claim is processed by TPA)/Company (if claim is processed by the Company) in writing by
letter, e-mail, fax providing all relevant information relating to claim including plan of treatment, policy number etc. within the
prescribed time limit.
Claim Intimation in case of Cashless facility TPA must be informed:

In the event of planned hospitalisation At least seventy two hours prior to the insured person’s
admission to network provider
In the event of emergency hospitalisation Within twenty four hours of the insured person’s admission to
network provider
Claim Intimation in case of Reimbursement Company/TPA must be informed:
In the event of planned hospitalization or domiciliary At least seventy two hours prior to the insured person’s
hospitalistion admission to hospital/ commencement of Domiciliary
Hospitalisation
In the event of emergency hospitalization or domiciliary Within twenty four hours of the insured person’s admission to
hospitalistion hospital/ commencement of Domiciliary Hospitalisation
6.5.2 Procedure for Cashless Claims

i. Cashless facility for treatment in network providers can be availed, if TPA service is opted.
ii. Treatment may be taken in a network provider and is subject to pre authorization by the TPA. Booklet containing list of
network provider shall be provided by the TPA. Updated list of network provider is available on website of the Company and
the TPA mentioned in the schedule.
iii. Cashless request form available with the network provider and TPA shall be completed and sent to the TPA for authorization.
iv. The TPA upon getting cashless request form and related medical information from the insured person/ network provider shall
issue pre-authorization letter to the hospital after verification.
v. At the time of discharge, the insured person has to verify and sign the discharge papers, pay for non-medical and inadmissible
expenses.
vi. The TPA reserves the right to deny pre-authorization in case the insured person/ network provider is unable to provide any
required details related to the pre authorization request.
vii. In case of denial of cashless facility, the insured person may obtain the treatment as per treating medical practitioner’s advice
and submit the necessary documents for reimbursement of claim.
6.5.3 Procedure for Reimbursement of Claims

For reimbursement of claims the insured person shall submit the necessary documents to TPA (if claim is processed by
TPA)/Company (if claim is processed by the Company) within the prescribed time limit.
6.5.3.1 Procedure for Reimbursement of Claim under Domiciliary Hospitalisation

For reimbursement of claims under domiciliary hospitalisation, the insured person shall submit the necessary documents to TPA
(if claim is processed by TPA)/Company (if claim is processed by the Company) within the prescribed time limit.
Kolkata 700071
6.5.4 Documents
The claim is to be supported with the following original documents and submitted within the prescribed time limit.
i. Completed claim form
ii. Medical practitioner’s prescription advising admission for inpatient treatment.
iii. Cash-memo from the hospital (s)/chemist (s) supported by proper prescription from attending medical practitioner for Pre
Hospitalization, Hospitalization and Post Hospitalization.
iv. Payment receipt, investigation test reports, supported by the prescription from attending medical practitioner for Pre
Hospitalization, Hospitalization and Post Hospitalization.
v. Attending medical practitioner’s certificate regarding diagnosis along with date of diagnosis and bill, receipts etc.
vi. Surgeon’s certificate regarding diagnosis and nature of operation performed along with bills, receipts etc.
vii. Bills, receipt, Sticker of the Implants.
viii. Bills, payment receipts, medical history of the patient recorded, discharge certificate/ summary, break up of final bill from the
hospital etc.
ix. For claim under Section Domiciliary Hospitalisation in addition to documents listed above (as applicable), medical certificate
stating the circumstances requiring for Domiciliary hospitalisation and fitness certificate/ medical certificate of state of patient
from treating medical practitioner.
x. For claim under Section Funeral Expense, certificate of death of insured person (original shall be returned following
verification).
xi. Any other document required by Company/TPA.
Note
In the event of a claim lodged under the Policy and the original documents having been submitted to any other insurer, the
Company shall accept the copy of the documents listed under condition 6.5.4 and claim settlement advice, duly certified by the
other insurer subject to satisfaction of the Company.
6.5.5 Time limit for submission of claim documents to the Company/ TPA
Type of claim Time limit
Reimbursement of hospitalisation, pre hospitalisation Within 30 days of date of discharge from hospital
expenses and ambulance charges
Reimbursement of post hospitalisation expenses and Within 30 days from completion of post hospitalisation
doctor’s home visit and nursing care during post treatment
hospitalization
Reimbursement of domiciliary hospitalisation expenses Within 30 days from completion of issuance of fitness
certificate/ medical certificate on state of patient
Reimbursement of preventive health check-up expenses Within 6 (six) months of the completion of a block of 2 policy
under Plan A period (to be submitted to the policy issuing office only)
Reimbursement of preventive health check-up expenses Once every year, within 30 days from expiry of policy (to be
under Plan B submitted to the policy issuing office only)
Waiver
Time limit for claim intimation and submission of documents may be waived in cases where the insured/ insured person or his/
her representative applies and explains to the satisfaction of the Company, that the circumstances under which insured/ insured
person was placed, it was not possible to intimate the claim/submit the documents within the prescribed time limit.
6.5.6 Claim Settlement

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last necessary
document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder from the date
of receipt of last necessary document to the date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall initiate and
complete such investigation at the earliest, in any case not later than 30 days from the date of receipt of last necessary document.
In such cases, the Company shall settle or reject the claim within 45 days from the date of receipt of last necessary document.
iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a rate 2%
above the bank rate from the date of receipt of last necessary document to the date of payment of claim.
(Explanation: “Bank rate” shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the financial year in
which claim has fallen due)
6.5.7 Services Offered by TPA

Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-authorization of cashless treatment or
processing of claims other than cashless claims or both, as per the underlying terms and conditions of the policy.
The services offered by a TPA shall not include
i. Claim settlement and claim rejection;
ii. Any services directly to any insured person or to any other person unless such service is in accordance with the terms and
conditions of the Agreement entered into with the Company.
Kolkata 700071
6.5.8 Treatment in Non-Network Provider
Claims where treatment is undergone in a non-network provider in PPN cities shall be restricted to the PPN rates for same
procedure in similar hospital in the city. If treatment is undergone in a non-network provider in a city/ town/ village where the
Company/ TPA does not have tie-up with any hospital, the condition shall not apply.
6.6 Moratorium Period

After completion of eight continuous years under this policy no look back would be applied. This period of eight years is called as
moratorium period. The moratorium would be applicable for the sums insured of the first policy and subsequently completion of
eight continuous years would be applicable from date of enhancement of sums insured only on the enhanced limits. After the
expiry of Moratorium Period no claim under this policy shall be contestable except for proven fraud and permanent exclusions
specified in the policy contract. The policies would however be subject to all limits, sub limits, co-payments as per the policy.
6.7 Payment of Claim

All claims under the policy shall be payable in Indian currency and through NEFT/ RTGS only.
6.8 Territorial Limit

All medical treatment for the purpose of this insurance will have to be taken in India only.
6.9 Multiple Policies

i. In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs,
the insured person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases
the insurer chosen by the insured person shall be obliged to settle the claim as long as the claim is within the limits of and
according to the terms of the chosen policy.
ii. Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed
under any other policy / policies even if the sum insured is not exhausted. Then the insurer shall independently settle the claim
subject to the terms and conditions of this policy.
iii. If the amount to be claimed exceeds the sum insured under a single policy, the insured person shall have the right to choose
insurer from whom he/she wants to claim the balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured
person shall only be indemnified the treatment costs in accordance with the terms and conditions of the chosen policy.
6.10 Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in
support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain
any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all
recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to
the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts committed by the insured person or by his
agent or the hospital/doctor/any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce
the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person /
beneficiary can prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress
the fact or that such misstatement of or suppression of material fact are within the knowledge of the insurer.
6.11 Cancellation
i. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material facts, fraud by
the insured person by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts or fraud
ii. The policyholder may cancel this policy by giving 15days’ written notice and in such an event, the Company shall refund
premium for the unexpired policy period as detailed below.
Period of risk Rate of premium to be charged

Up to 1month 1/4 of the annual rate
Up to 3 months 1/2 of the annual rate
Up to 6 months 3/4 of the annual rate
Exceeding 6 months Full annual rate
6.12 Territorial Jurisdiction

All disputes or differences under or in relation to the policy shall be determined by the Indian court and according to Indian law.
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6.13 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy (liability being otherwise admitted) such
difference shall independently of all other questions, be referred to the decision of a sole arbitrator to be appointed in writing
by the parties here to or if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration, the
same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to be appointed by each of the parties to
the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under
and in accordance with the provisions of the Arbitration and Conciliation Act 1996, as amended by Arbitration and
Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
ii. It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if
the Company has disputed or not accepted liability under or in respect of the policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the
policy that award by such arbitrator/arbitrators of the amount of expenses shall be first obtained.
6.14 Disclaimer of Liability

If the Company shall disclaim liability to the insured person for any claim hereunder and if the insured person shall not within
twelve calendar months from the date of receipt of the notice of such disclaimer notify the Company in writing that he does not
accept such disclaimer and intends to recover his claim from the Company, then the claim shall for all purposes be deemed to
have been abandoned and shall not thereafter be recoverable hereunder.
6.15 Renewal of Policy

The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured person.
i. The Company shall endeavor to give notice for renewal. However, the Company is not under obligation to give any notice
for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.
iv. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to
maintain continuity of benefits without break in policy. Coverage is not available during the grace period.
v. No loading shall apply on renewals based on individual claims experience.
6.16 Enhancement of Sum Insured

Sum insured can be enhanced only at the time of renewal. Sum insured can be enhanced to the next higher slab subject to
discretion of the Company. For the incremental portion of the sum insured, the waiting periods and conditions as mentioned in
exclusion 4.1, 4.2, 4.3 shall apply afresh.
6.17 Adjustment of Premium for Overseas Travel Insurance Policy

If during the policy period any of the insured person is also covered by an Overseas Travel Insurance Policy of any Non-Life
Insurance Company, the Policy shall be inoperative in respect of the insured persons for the number of days the Overseas Travel
Insurance Policy is in force. Proportionate premium for such number of days shall be adjusted against the renewal premium,
provided the insured has informed the Company in writing before leaving India, and submits an application, stating the details of
visit(s) abroad, along with copies of the Overseas Travel Insurance Policy, within fifteen days of return. The maximum premium
refundable and adjusted on renewal shall be limited to 80% of premium of the expiring Policy, in respect of the insured person(s)
covered under Overseas Travel Insurance Policy.
6.18 Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company by
applying for migration of the policyatleast30 days before the policy renewal date as per IRDAI guidelines on Migration. If such
person is presently covered and has been continuously covered without any lapses under any health insurance product/plan offered
by the company, the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on
migration.
6.19 Portability
The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy
along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal date
as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any
lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued
continuity benefits in waiting periods as per IRDAI guidelines on portability.
6.20 Withdrawal of Product

i. In the likelihood of this product being withdrawn in future, the Company will intimate the insured person about the same 90
days prior to expiry of the policy.
ii. Insured Person will have the option to migrate to similar health insurance product available with the Company at the time of
renewal with all the accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI
guidelines, provided the policy has been maintained without a break.
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6.21 Revision of Terms of the Policy Including the Premium Rates
The Company, with prior approval of IRDAI, may revise or modify the terms of the policy including the premium rates. The
insured person shall be notified three months before the changes are effected.
6.22 Free look period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or at the time of
porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days from date of receipt of the policy document to review the
terms and conditions of the policy, and to return the same if not acceptable.
If the insured has not made any claim during the Free Look Period, the insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by the Company on medical examination of the insured person and
the stamp duty charges or
ii. where the risk has already commenced and the option of return of the policy is exercised by the insured person, a deduction
towards the proportionate risk premium for period of cover or
iii. Where only a part of the insurance coverage has commenced, such proportionate premium commensurate with the
insurance coverage during such period.
6.23 Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the
policy in the event of death of the policyholder. Any change of nomination shall be communicated to the company in writing and
such change shall be effective only when an endorsement on the policy is made. In the event of death of the policyholder, the
Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no
subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final
discharge of its liability under the policy.
7 REDRESSAL OF GRIEVANCE
In case of any grievance the insured person may contact the company through
Website: http://nationalinsurance.nic.co.in/ Courier: National Insurance Co. Ltd.,
Toll free: 1800 345 0330 6A Middleton Street, 7th Floor,
E-mail: customer.relations@nic.co.in CRM Dept.,
Phn : (033) 2283 1742 Kolkata - 700 071
Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the
grievance officer (Office in-Charge) at that location.
For updated details of grievance officer, kindly refer the link: http://nationalinsurance.nic.co.in/
If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the
office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance Ombudsman Rules 2017
(Annexure IV).
Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
8 OPTIONAL COVERS
Cover for Pre-existing Diabetes and/ or Hypertension, Outpatient Treatment, Critical Illness and Personal Accident are available
as Optional Covers on payment of additional premium. The Optional Cover has to be opted on inception or renewal, and cannot
be changed/ removed on mid-term of the policy.
8.1 PRE-EXISTING DIABETES / HYPERTENSION

Subject otherwise to the terms, definitions, exclusions, and conditions of the Policy and on payment of additional premium, the
Company shall waive Exclusion 4.1 in respect of pre-exiting diabetes and/ or hypertension only and pay for expenses for such
treatment from inception of the policy, subject to the Co-payment, for the first twenty four months of insurance. On completion of
continuous twenty four months of insurance, the additional premium and co-payment shall not apply.
Limit of Cover
Sum Insured under the policy shall apply, on Individual Basis or Floater Basis as opted.
Co-payment
Claims shall be subject to a co-payment on admissible claim amount as mentioned below
i. Insured opting for cover for pre-existing diabetes for the first two policy periods, can avail treatment for diabetes, subject to a
co-payment of 10%
ii. Insured opting for cover for pre-existing hypertension for the first two policy periods, can avail treatment for hypertension,
subject to a co-payment of 10%
iii. Insured opting for cover for pre-existing diabetes and hypertension for the first two policy periods, can avail treatment for
diabetes or hypertension, subject to a co-payment of 25%
Renewal
This Optional Cover can be renewed annually till Exclusion 4.1 applies on diabetes and/or hypertension, with respect to the
insured persons.
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8.2 OUT-PATIENT TREATMENT
Subject otherwise to the terms, definitions, conditions, exclusions 5.9 (Drug/Alcohol Abuse), 5.7 (Breach of Law), 5.33 (War),
5.34 (Radioactivity) and on payment of additional premium, the Company shall pay up to the limit, as stated in the schedule with
respect of
i. Out-patient consultations by a medical practitioner or psychiatrist
ii. Diagnostic tests prescribed by a medical practitioner or psychiatrist
iii. Medicines/drugs prescribed by a medical practitioner or psychiatrist
iv. Out-patient dental treatment
Limit of cover
Limit of cover, available under Outpatient Treatment are INR 2,000 / 4,000 / 5,000 / 7,500/ 10,000/ 15,000. The limit of cover
may be utilized by one or all individuals covered under the policy irrespective of the type of Policy (as per Section 2.1).
Enhancement of limit of cover

i. Limit of cover can be enhanced only at the time of renewal.
ii. Limit of cover can be enhanced to the next slab subject to discretion of the Company.
8.2.1 Exclusions
The Company shall not make any payment under this Optional Cover in respect of
i. Treatment other than Allopathy/ Modern medicine, Ayurveda and Homeopathy
ii. * Cosmetic dental treatment to straighten, lighten, reshape, repair and replace teeth.
* Cosmetic dental treatments include veneers, bridges, tooth-coloured fillings, implants and tooth whitening.
8.2.2 Condition
Claim amount
Any amount payable under this optional cover will be subject to the limit of cover mentioned in schedule, and not affect the sum
insured applicable to the Policy or entitlement to Good Health Incentives.
Claims Procedure
Documents supporting all out-patient treatments shall be submitted to the Company/ TPA once in a policy period either after the
exhaustion of the limit or within 30 days from expiry of policy, whichever is earlier.
Documents
The claim is to be supported with the following original documents
i. All cash memos with supporting prescriptions from medical practitioner
ii. Diagnostic test bills and receipts, copy of reports with supporting prescriptions from medical practitioner
iii. Any other documents required by the Company/ TPA
8.3 CRITICAL ILLNESS

Subject otherwise to the terms, definitions, exclusions, conditions contained herein and on payment of additional premium, the
Company shall pay the benefit amount, as stated in the schedule, provided that
i. the insured person is first diagnosed as suffering from a critical illness (as defined) during the policy period, and
ii. the insured person survives for at least 30 (thirty) days following such diagnosis
iii. diagnosis of critical illness is supported by clinical, radiological, histological and laboratory evidence acceptable to the
Company.
Benefit amount
Benefit amount options available per individual insured person are INR 1,00,000/ 2,00,000/ 3,00,000/ 4,00,000/ 5,00,000/
6,00,000/ 7,00,000/ 8,00,000/ 9,00,000/ 10,00,000 or the individual/ floater Sum Insured under the policy, whichever is lower.
Maximum Benefit amount each insured person can opt under Critical Illness cover shall be the individual/ floater Sum Insured
under the policy.
Enhancement of benefit amount

i. Benefit amount can be enhanced only at the time of renewal.
ii. Benefit amount can be enhanced to the next slab subject to discretion of the Company, up to the individual/ floater Sum
Insured under the policy
8.3.1 Definition
Critical illness means (i) Cancer of Specified Severity, (ii) Myocardial Infarction (First Heart Attack of Specified Severity), (iii)
Open Chest Coronary Artery Bypass Graft Surgery, (iv) Open Heart Replacement or Repair of Heart Valves, (v) Coma of
Specified Severity, (vi) Kidney Failure requiring Regular Dialysis, (vii) Stroke Resulting in Permanent Symptoms, (viii) Major
Organ/Bone Marrow Transplant, (ix) Permanent Paralysis of Limbs, (x) Motor Neuron Disease with Permanent Symptoms and
(xi) Multiple Sclerosis with Persisting Symptoms.
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8.3.1.1 Cancer of Specified Severity
A malignant tumor characterised by the uncontrolled growth & spread of malignant cells with invasion & destruction of normal
tissues. This diagnosis must be supported by histological evidence of malignancy. The term cancer includes leukemia, lymphoma
and sarcoma.
The following are excluded

i. All tumors which are histologically described as carcinoma in situ, benign, pre-malignant, borderline malignant, low
malignant potential, neoplasm of unknown behavior, or non- invasive, including but not limited to:
Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
ii. Any non- melanoma skin carcinoma unless there is evidence of metastases to lymph nodes or beyond;
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumors of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at
least clinical TNM classification T2N0M0;
v. All Thyroid cancers histologically classified as T1N0M0 (TNM classification) or below;
vi. Chronic lymphocytic leukaemia less than RAI stage 3
vii. Non- invasive Papillary cancer of bladder histologically described as TaN0M0 (TNM Classification)or of a lesser
classification;
viii. All Gastro-intestinal Stromal Tumors histologically classified as T1N0M0 (TNM Classification) or below and with mitotic
count of less than or equal to 5/50 HPFs;
ix. All tumors in the presence of HIV infection.
8.3.1.2 Myocardial Infarction (First Heart Attack of Specified Severity)

The first occurrence of heart attack or myocardial infarction, which means the death of a portion of the heart muscle as a result of
inadequate blood supply to the relevant area. The diagnosis for Myocardial Infarction should be evidenced by all of the following
criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. typical chest
pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

i. Other acute Coronary Syndromes.
ii. Any type of angina pectoris.
iii. A rise in cardiac biomarkers or Troponin T or I in absence of over ischemic heart disease OR following an intra-arterial
cardiac procedure
8.3.1.3 Open Chest Coronary Artery Bypass Graft Surgery (CABG)

The actual undergoing of Heart surgery to correct blockage or narrowing in one or more coronary artery(s), by coronary artery
bypass grafting done via sternotomy (cutting through breast bone) or minimally invasive keyhole coronary artery bypass
procedures. The diagnosis must be supported by a coronary angiography and the realization of surgery has to be confirmed by a
cardiologist.

Angioplasty and/or any other intra-arterial procedures.
8.3.1.4 Open Heart Replacement or Repair of Heart Valve

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart valves, as a consequence of defects in,
abnormalities of, or disease-affected cardiac valve(s). The diagnosis of the valve abnormality must be supported by an
echocardiography and the realization of surgery has to be confirmed by a specialist medical practitioner.

Catheter based techniques including but not limited to, balloon valvotomy/ valvuloplasty are excluded.
8.3.1.5 Coma of Specified Severity

A state of unconsciousness with no reaction or response to external stimuli or internal needs.
This diagnosis must be supported by evidence of all of the following:
i. No response to external stimuli continuously for at least 96 hours;
ii. Life support measures are necessary to sustain life; and
iii. Permanent neurological deficit which must be assessed at least 30 days after the onset of the coma.
The condition has to be confirmed by a specialist Medical Practitioner.

Coma resulting directly from alcohol or drug abuse is excluded.
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8.3.1.6 Kidney Failure requiring Regular Dialysis
End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as a result of which either regular
renal dialysis (hemodialysis or peritoneal dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be
confirmed by a specialist medical practitioner.
8.3.1.7 Stroke Resulting in Permanent Symptoms

Any cerebrovascular incident producing permanent neurological sequelae. This includes infarction of brain tissue, thrombosis in
an intracranial vessel, haemorrhage and embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist
medical practitioner and evidenced by typical clinical symptoms as well as typical findings in CT Scan or MRI of the brain.
Evidence of permanent neurological deficit lasting for at least 3 months has to be produced.
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.
8.3.1.8 Major Organ/ Bone Marrow Transplant

The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from irreversible end-stage failure of the
relevant organ, or
ii. Human bone marrow using haematopoietic stem cells.
The undergoing of a transplant has to be confirmed by a specialist medical practitioner.
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
8.3.1.9 Permanent Paralysis of Limbs

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the brain or spinal cord. A specialist
medical practitioner must be of the opinion that the paralysis will be permanent with no hope of recovery and must be present for
more than 3 months.
8.3.1.10 Motor Neuron Disease with Permanent Symptoms

Motor Neuron disease diagnosed by a specialist medical practitioner as spinal muscular atrophy, progressive bulbar palsy,
amyotrophic lateral sclerosis or primary lateral sclerosis. There must be progressive degeneration of corticospinal tracts and
anterior horn cells or bulbar efferent neurons. There must be current significant and permanent functional neurological impairment
with objective evidence of motor dysfunction that has persisted for a continuous period of at least 3 months.
8.3.1.11 Multiple Sclerosis with Persisting Symptoms

The unequivocal diagnosis of Definite Multiple Sclerosis confirmed and evidenced by all of the following
i. Investigations including typical MRI findings, which unequivocally confirm the diagnosis to be multiple sclerosis and
ii. There must be current clinical impairment of motor or sensory function, which must have persisted for a continuous period of
at least 6 months
Other causes of neurological damage such as SLE and HIV.
8.3.2 Exclusions
The Company shall not be liable to make any payment under the Policy for any critical illness which were present at any time
before inception of the Policy, or which manifest within a period of ninety days from inception of the Policy. In the event of break
in the Policy, the terms of this exclusion shall apply as new from the date of recommencement of cover
8.3.3 Condition
Claim Amount
Any amount payable under the optional covers will be subject to the benefit amount mentioned in schedule, and not affect the sum
insured applicable to the Policy or entitlement to Good Health Incentives.
Notification of Claim
In the event of a claim, the insured person/insured person’s representative shall intimate the Company in writing by letter, e-mail,
fax providing all relevant information relating to the critical illness within fifteen days of diagnosis of the critical illness.
Claims Procedure
Documents as mentioned below, supporting the diagnosis shall be submitted to the Company within sixty days (including survival
period of thirty days) from the date of diagnosis of the critical illness.
Documents
The claim has to be supported by the following original documents
i. Doctor’s certificate confirming diagnosis of the critical illness along with date of diagnosis.
ii. Pathological/other diagnostic test reports confirming the diagnosis of the critical illness.
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iii. Any other documents required by the Company
Cessation of Cover
i. Upon occurrence of a Critical Illness and payment of the benefit amount to the insured person, the cover shall cease in respect
of the insured person for the remaining policy period.
ii. In case a claim has been paid to any insured person for a Critical Illness, in subsequent renewals no claim shall be paid to that
insured person for the same critical illness or for any other Critical Illness induced by/arising out of that Critical Illness.
However, claim for all other Critical Illnesses covered under the Policy shall be admitted, subject to terms and conditions of
the Policy.
8.4 PERSONAL ACCIDENT

Subject otherwise to the terms, definitions, exclusions, conditions contained herein and on payment of additional premium, if
during the policy period the insured person shall sustain any injury anywhere in the world due to an accident resulting to death or
disability, the Company shall pay the amount specific to each section as herein after mentioned, subject to the capital sum insured
(CSI) opted.
8.4.1 Coverage
The Company shall pay to the insured or his/her nominee the amount mentioned against the relevant section.
a) Death
If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of death of the insured, the CSI
applicable to the insured person.
b) Loss by Physical Separation or Loss of Use of Two Limbs or Two Eyes or One Limb and One Eye
If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss
of
i. sight of both eyes or the actual loss by physical separation of the two hands or two feet or of one hand and one foot or loss
of sight of one eye and loss of one hand or one foot, the CSI applicable to the insured person.
ii. use of two hands or two feet or one hand and one foot without physical separation or loss of sight of one eye and loss of
use of one hand or one foot without physical separation, the CSI applicable to the insured person.
c) Loss by Physical Separation or Loss of Use of One Limb or One Eye

of
i. sight of one eye or the actual loss by physical separation of one hand or one foot, 50% of the CSI applicable to the insured
person.
ii. use of a hand or a foot without physical separation, 50% of the CSI applicable to the insured person
d) Permanent Total Disablement

If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of permanently totally and
absolutely disabling the insured from engaging in any employment or occupation of any description whatsoever, a lump sum
equal to 100% of the CSI applicable to the insured person.
e) Permanent Partial Disablement

of use or of the actual loss by physical separation of the following, the percentage of the CSI indicated below:
Percentage of Personal Accident Benefit
Loss of part of body
Amount
All 20
Great-both phalanges 5
Loss of toes
Great-one phalanx 2
Other than great, if more than one toe lost each 1
both ears 50
Loss of hearing
one ear 15
Loss of 4 fingers and thumb of 1 hand 40
Loss of 4 fingers of 1 hand 35
Both phalanges 25
Loss of thumb
One phalange 10
3 phalanges 4
Loss of Little finger 2 phalanges 3
1 phalange 2
3 phalanges 5
Loss of ring finger 2 phalanges 4
1 phalange 2
3 phalanges 6
Loss of middle finger
2 phalanges 4
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Percentage of Personal Accident Benefit
Loss of part of body
Amount
1 phalange 2
3 phalanges 10
Loss of Index finger 2 phalanges 8
1 phalange 4
1st or 2nd (additional) 3
Loss of metacarpal
3rd, 4th, or 5th (additional) 2
Any other permanent
% as assessed by panel doctor of the Company
partial disablement
Benefit amount
Capital Sum Insured (CSI) options available per individual insured person are INR 1,00,000/ 2,00,000/ 3,00,000/ 4,00,000/
5,00,000/ 6,00,000/ 7,00,000/ 8,00,000/ 9,00,000/ 10,00,000 or the individual/ floater Sum Insured under the policy, whichever is
lower.
Maximum Capital Sum Insured (CSI) each insured person can opt under Critical Illness cover shall be the individual/ floater Sum
Insured under the policy.
Enhancement of CSI
i. CSI amount can be enhanced only at the time of renewal.
ii. CSI amount can be enhanced to the next slab subject to discretion of the Company, up to the individual/ floater Sum Insured
under the policy.
8.4.2 Exclusions
The Company shall not be liable to make any payment in connection with or in respect of
8.4.2.1 Pre-existing Injury/ Disablement

Any disablement or death directly or indirectly arising out of or contributed to be or traceable to any disability or injury
existing on the date of issue of this Policy.
8.4.2.2 Racing, Hunting, Mountaineering and Winter Sports

Any injury while racing on wheels or horseback, hunting, big game shooting, mountaineering or whilst engaged in winter
sports- skiing and ice hockey.
8.4.2.3 Aviation or Ballooning

Any injury while the insured is engaged in aviation or ballooning
8.4.2.4 Non- fare Paying Passenger in Aircraft

Any injury while the insured is mounting into, dismounting from or travelling in any aircraft other than as a passenger (fare
paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world
8.4.2.5 Payment of compensation in respect of death, injury or disablement of the insured –

i. from intentional self-injury, suicide or attempted suicide
ii. whilst under the influence of intoxication liquor or drug
iii. Directly or indirectly caused by venereal disease or insanity
iv. Arising or resulting from the insured committing any breach of the law with criminal intent.
8.4.3 Conditions
Limits of compensation
The Company shall not be liable to make any payment in respect of
i. More than one of the sub clauses of Section 8.4.1 (Coverage) in respect of the same period of disablement.
ii. Any claim after a claim under one of the clauses (8.4.1.a), (8.4.1.b) or (8.4.1.d) has been admitted and is payable.
8.4.3.1 Claim documents

Duly completed claim form
In addition, the following documents are to be submitted depending on the nature of the claim.
Death
i. Attending Medical Practitioner’s report
ii. Original Policy for cancellation
iii. Original Death Certificate
iv. Original / attested post mortem / coroner’s report, where applicable
v. Attested copy of FIR / Panchnama
vi. Police inquest report, where applicable
vii. Any other document required by the Company
Post mortem report if necessary, shall be furnished within fourteen days, after demanded in writing
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Permanent Total Disablement/ Permanent Partial Disablement/ Temporary Total Disablement
i. Attending Medical Practitioner’s report
ii. Original Policy for cancellation in case of Permanent Total Disablement
iii. Original Policy for reduction in CSI in case of Permanent Partial Disablement/ Temporary Total Disablement
iv. Disability certificate from Medical Practitioner, where applicable
v. Diagnostic reports like laboratory test, X- rays and/ or any other reports confirming injury
vi. Police inquest report, where applicable
vii. Any other document required by the Company
9 Disclaimer
The prospectus contains salient features of the policy. For details reference is to be made to the Policy. In case of any difference
between the prospectus and the policy, the terms and conditions of the policy shall prevail.
The prospectus and proposal form are part of the policy. Hence please read the prospectus carefully and sign the same. The
proposal form is to be completed in all respects for each insured person. Both the prospectus and the proposal form are to be
submitted to the office or to the agent.
No loading shall apply on renewals based on individual claims experience

Insurance is the subject matter of solicitation
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Table of Benefits
Name of Product National Senior Citizen Mediclaim Policy
Plans Plan A (Individual and Floater) Plan B (Individual and Floater)
Sum Insured INR 1L to 10L INR 1L to 10L
Slab In multiple of 1,00,000 In multiple of 1,00,000
Coverage
Room – 1% of SI per day subject to maximum of Room – 2% of SI per day subject to maximum of INR
INR 5,000 per day 10,000 per day
ICU – 2% of SI per day subject to maximum of ICU – 4% of SI per day subject to maximum of INR
INR 10,000 per day 20,000 per day
Overall Limit No overall limit
A. Room/ ICU – 25% of SI per illness
In patient Treatment*
B. Medical Practitioner’s fee - 25% of SI per
illness
C. Others – 50% of SI per illness
Cataract - 15% of SI or INR 75,000 for each eye, Cataract - Actual
whichever is lower Benign Prostatic Hyperplasia – Actual
Benign Prostatic Hyperplasia – 20% of SI
System of Medicine Allopathy, Ayurveda, Homeopathy Allopathy, Ayurveda, Homeopathy
Pre hospitalisation 30 days immediately before hospitalisation 30 days immediately before hospitalisation
Post hospitalisation 60 days immediately after discharge 60 days immediately after discharge
Domiciliary Hospitalisation Up to 20% of the Sum Insured Up to 20% of the Sum Insured
Day Care Procedures 140 day care procedures 140 day care procedures
Ayurveda and Homeopathy Up to Sum Insured Up to Sum Insured
Organ Donor’s Medical Medical expenses, Pre & Post Hospitalisation Medical expenses, Pre & Post Hospitalisation expenses
Expenses expenses up to Sum Insured up to Sum Insured
Ambulance Charges Up to INR 2,500 per illness Up to INR 2,500 per illness
Modern Treatment (12 nos) Up to 25% of SI for each treatment Up to 25% of SI for each treatment
Treatment due to Up to 25% of SI Up to 25% of SI
participation in hazardous or
adventure sports (non-
professionals)
Morbid Obesity Covered after waiting period of 4 years Covered after waiting period of 4 years
Refractive Error (min 7.5D) Covered after waiting period of 2 years Covered after waiting period of 2 years
Hospital cash (per individual) x INR 500/- per day for 5 days (in excess 3 days)
Aya, Doctor's home visit
charges and nursing care
x INR 500/- per day for 7 days
during post hospitalisation
(per individual)
Reinstatement of SI for road
x Once during the policy period
traffic accidents
Funeral expenses (per
x Up to INR 5,000
individual)
Others
Pre Existing Disease Only PEDs declared in the Proposal Form and accepted for coverage by the Company shall be covered after 2
year
Optional Cover (on payment of extra premium)
Pre-existing Diabetes and/ or Up to the SI
Hypertension
Outpatient Treatment Limit of cover per family - 2,000 / 4,000 / 5,000 / 7,500/ 10,000/ 15,000
Critical Illness ** Benefit amount per individual- INR 1,00,000/ 2,00,000/ 3,00,000/ 4,00,000/ 5,00,000/ 6,00,000/ 7,00,000/
8,00,000/ 9,00,000/ 10,00,000
Personal Accident ** Capital Sum Insured per individual – INR 1,00,000/ 2,00,000/ 3,00,000/ 4,00,000/ 5,00,000/ 6,00,000/
7,00,000/ 8,00,000/ 9,00,000/ 10,00,000
Good Health Incentives
Cumulative Bonus Increase by 5% of SI in respect of each claim free Increase by 5% of SI in respect of each claim free year
year of insurance of insurance
Decrease by 5% of SI for each year with claim Decrease by 5% of SI for each year with claim reported
reported
Preventive Health Check Up Every 2 claim free years, prescribed diagnostics Every 6 claim free months, Regular medical
tests up to 2 % of the average SI (excluding CB) consultation and prescribed diagnostics tests up to INR
per insured person (individual basis) or family 1,000 per insured person (irrespective of individual basis
(floater basis), subject to maximum INR 4,000/- per or floater basis)
insured person (individual basis) or per family
(floater basis)
Discounts
Direct Discount 10% discount (provided no intermediary is involved)
* The limit shall not apply if the treatment is undergone for a listed procedure in a Preferred Provider Network (PPN) as a package.
** Critical Illness benefit amount and Personal Accident Capital Sum Insured should not be more than the sum insured opted under the Policy
Kolkata 700071
Rate Chart (in INR)
Plan A – Premium Table for Individuals / Premium Table for Senior most member (for floater policy)
SI 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
60-65 7,313 11,427 14,284 16,456 19,746 23,696 28,009 30,809 32,388 33,360
66-70 10,970 17,141 21,426 24,683 29,619 35,544 42,013 46,214 48,582 50,040
71-75 12,638 19,747 24,684 28,436 34,124 40,948 48,401 53,241 55,969 57,648
76-80 14,454 22,586 28,232 32,524 39,029 46,834 55,358 60,894 64,014 65,935
81-85 19,047 29,761 37,201 42,855 51,427 61,712 72,945 80,239 84,350 86,881
86+ 20,951 32,738 40,921 47,141 56,570 67,884 80,239 88,263 92,784 95,569
Plan A - Premium Table for spouse (for floater policy)

SI 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
50-55 1,332 2,081 2,602 2,997 3,596 4,316 5,101 5,611 5,899 6,075
56-60 2,358 3,684 4,605 5,305 6,366 7,640 9,030 9,933 10,441 10,755
61-65 3,657 5,714 7,142 8,228 9,873 11,848 14,005 15,405 16,194 16,680
66-70 5,693 8,897 11,121 12,811 15,372 18,447 21,804 23,985 25,215 25,971
71-75 6,812 10,644 13,305 15,327 18,393 22,071 26,088 28,698 30,168 31,073
76-80 8,094 12,648 15,810 18,213 21,856 26,227 31,000 34,101 35,848 36,923
81-85 11,066 17,291 21,614 24,899 29,879 35,855 42,380 46,619 49,007 50,477
86+ 13,619 21,280 26,599 30,641 36,770 44,125 52,155 57,371 60,310 62,119
Plan B – Premium Table for Individuals / Premium Table for Senior most member (for floater policy)
SI 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
60-65 10,419 16,280 20,350 23,443 28,132 33,759 39,902 43,893 46,142 47,526
66-70 15,628 24,420 30,525 35,165 42,198 50,637 59,854 65,839 69,213 71,289
71-75 17,906 28,134 35,167 40,512 48,614 58,337 68,955 75,850 79,737 82,129
76-80 20,387 32,177 40,221 46,334 55,602 66,722 78,867 86,753 91,198 93,934
81-85 26,310 42,399 52,999 61,054 73,266 87,919 1,03,921 1,14,312 1,20,170 1,23,775
86+ 28,941 46,639 58,298 67,160 80,592 96,711 1,14,312 1,25,743 1,32,187 1,36,153
Plan B - Premium Table for spouse (for floater policy)

SI 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
50-55 1,897 2,965 3,707 4,269 5,124 6,149 7,267 7,994 8,404 8,656
56-60 3,359 5,249 6,560 7,558 9,070 10,883 12,865 14,151 14,875 15,323
61-65 5,209 8,141 10,176 11,722 14,066 16,880 19,951 21,947 23,072 23,764
66-70 8,111 12,674 15,842 18,250 21,901 26,280 31,064 34,170 35,922 36,999
71-75 9,651 15,164 18,955 21,836 26,203 31,443 37,167 40,883 42,979 44,268
76-80 11,417 18,019 22,524 25,948 31,137 37,364 44,165 48,581 51,071 52,603
81-85 15,286 24,633 30,792 35,472 42,568 51,081 60,378 66,415 69,819 71,914
86+ 18,812 30,316 37,894 43,654 52,385 62,862 74,303 81,734 85,922 88,500
Note: Age band 50-55 and 56-60 shall only available to spouse in floater policy
The premiums rates given above are all inclusive of TPA charges and exclusive of GST.
For without TPA – 6% discount on the premiums tabulated above.
Kolkata 700071
Optional Cover
(a) Pre-existing diabetes/ hypertension

Cover Additional Premium with/ Copayment
without TPA
Pre-existing diabetes or Additional Premium of 13.5% of 10% copayment on admissible claim amount
Hypertension individual premium for diabetes or hypertension claims
Pre-existing diabetes and Additional Premium of 30% of 25% copayment on admissible claim amount
Hypertension individual premium for diabetes or hypertension claims
GST extra
If policy is with TPA – Additional Premium percentage shall apply on the individual premium as per Rate Chart
If policy is without TPA – Additional Premium percentage shall apply on the individual premium discounted by 6% as specified in
the Rate Chart.
(b) Outpatient treatment

Limit of cover 2,000 4,000 5,000 7,500 10,000 15,000
Premium 1,400 2,800 3,500 5,250 7,000 10,500
GST extra
(c) Critical Illness

Age Band 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
50-55 1,359 2,718 4,077 5,436 6,795 8,153 9,512 10,871 12,230 13,589
56-59 2,536 5,071 7,607 10,143 12,679 15,214 17,750 20,286 22,822 25,357
60-65 3,639 7,278 10,917 14,556 18,196 21,835 25,474 29,113 32,752 36,391
66-70 7,804 15,607 23,411 31,214 39,018 46,822 54,625 62,429 70,232 78,036
71-75 13,074 26,148 39,222 52,296 65,371 78,445 91,519 1,04,593 1,17,667 1,30,741
76-80 19,653 39,306 58,958 78,611 98,264 1,17,917 1,37,570 1,57,222 1,76,875 1,96,528
81-85 21,618 43,236 64,854 86,472 1,08,090 1,29,708 1,51,327 1,72,945 1,94,563 2,16,181
86+ 24,861 49,722 74,582 99,443 1,24,304 1,49,165 1,74,025 1,98,886 2,23,747 2,48,608
GST extra
(d) Personal Accident

CSI 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 6,00,000 7,00,000 8,00,000 9,00,000 10,00,000
Premium 90 180 270 360 450 540 630 720 810 900
GST extra
No loading shall apply on renewals based on individual claims experience

Insurance is the subject matter of solicitation
Kolkata 700071

National Senior Citizen Mediclaim Policy - Prospectus

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National Senior Citizen Mediclaim Policy - Prospectus

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National Insurance Company Limited

CIN - U10200WB1906GOI001713 IRDAI Regn. No. - 58

1.2.1.2 Limit for Cataract Surgery and Benign Prostatic Hyperplasia

1.2.1.3 Treatment related to participation as a non-professional in hazardous or adventure sports

1.2.2 Pre Hospitalisation

1.2.3 Post Hospitalisation

1.2.4 Domiciliary Hosptalisation

1.2.5 Daycare Procedure

1.2.6 Ayurveda and Homeopathy

1.2.7 HIV/ AIDS Cover

1.2.8 Mental Illness Cover

1.2.10 Ambulance Charges

1.2.11 Modern Treatment

1.2.12 Morbid Obesity Treatment

1.2.13 Correction of Refractive Error

1.3 ADDITIONAL BENEFITS AVAILABLE IN PLAN B

1.3.4Reinstatement of Sum Insured if exhausted due to Road Traffic Accident

1.4 GOOD HEALTH INCENTIVE

For policies issued on floater basis

1.4.2 Preventive Health Check Up

1.4.2.2 Applicable to Plan B

1.5 Hospitalisation Options

2.1 Type of Policy

2.4 Policy Period

2.6 Sum Insured (SI)

2.9 Completion of Proposal Form

2.10 Pre Policy Checkup

2.11 Payment of Premium

2.12 Renewal of Policy

4 WAITING PERIOD - EXCLUSIONS

4.1. Pre-Existing Diseases (Excl 01)

4.2. Specified disease/procedure waiting period (Excl 02)

4.3. First 30 days waiting period (Excl 03)

5.1. Investigation& Evaluation (Excl 04)

5.2. Rest Cure, Rehabilitation and Respite Care (Excl 05)

5.3. Obesity/ Weight Control (Excl 06)

5.4. Change-of-Gender Treatments (Excl 07)

5.6. Hazardous or Adventure Sports (Excl 09)

5.7. Breach of Law (Excl 10)

5.8. Excluded Providers (Excl 11)

5.9. Drug/Alcohol Abuse (Excl 12)

5.10. Non Medical Admissions (Excl 13)

5.11. Vitamins, Tonics (Excl 14)

5.12. Refractive Error (Excl 15)

5.13. Unproven Treatments (Excl16)

5.14. Birth control, Sterility and Infertility (Excl 17)

5.15. Maternity (Excl 18)

5.16. Hormone Replacement Therapy

5.17. General Debility, Congenital External Anomaly

5.18. Self Inflicted Injury

5.19. Stem Cell Surgery

5.23. Dental treatment

5.24. Out Patient Department (OPD) treatment

5.25. Stay in Hospital which is not Medically Necessary.

5.26. Spectacles, Contact Lens, Hearing Aid, Cochlear Implants

5.27. Non Prescription Drug

5.28. Treatment not Related to Disease for which Claim is Made

5.30. Items of personal comfort

5.31. Service charge/ registration fee

5.32. Home visit charges

5.35. Treatment taken outside the geographical limits of India